Search

Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020).

Vertebro-PICA aneurysms may be challenging because of their relationship with the brainstem and the lower cranial nerves, especially when the vertebral artery is tortuous and the aneurysm is located in front of the brainstem, contralaterally to the parent vertebral artery. We describe the surgical technique for safe approach. Cadaveric dissection performed by the authors, provided comprehensive understanding of relevant anatomy. Intraoperative photos and videos show clipping of the aneurysm using a combined midline and far-lateral suboccipital craniotomy with a para-condylar extension. The literature reviews potential complications. This combined approach allows safe clipping of such PICA aneurysms.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Background: Knowledge translation (KT) is an important means of improving health service quality. Most research on the effectiveness of KT strategies has focused on individual strategies, i.e., those targeting directly the modification of allied health professionals’ knowledge, attitudes, and behaviours, for example. In general, these strategies are moderately effective in changing practices (maximum 10% change). Effecting change in organizational contexts (e.g., change readiness, general and specific organizational capacity, organizational routines) is part of a promising new avenue to service quality improvement through the implementation of evidence-based practices.Methods: A realist review will be conducted to explore the various organizational KT strategy action mechanisms (how, why, for whom, to what extent and under what circumstances) with a view to facilitating the choice of effective strategies for sustainable implementation of evidence-based practice for allied health professionals in traumatology settings. The review will begin by presenting initial theories developed by the research team, followed by the search for evidence, the selection of literature on context-mechanism-outcome configurations related to organizational KT strategies, and end with a refinement of initial theories and a synthesis.Discussion: Using a systematic and rigorous method, this review will help guide decision makers and researchers in choosing the best organizational strategies to optimize the implementation of evidence-based practices.Registration: This protocol has been submitted for registration on the PROSPERO database on October 30, 2020 (ID: 216105).

Background Knowledge translation (KT) is an important means of improving the health service quality. Most research on the effectiveness of KT strategies has focused on individual strategies, i.e., those directly targeting the modification of allied health professionals’ knowledge, attitudes, and behaviors, for example. In general, these strategies are moderately effective in changing practices (maximum 10% change). Effecting change in organizational contexts (e.g., change readiness, general and specific organizational capacity, organizational routines) is part of a promising new avenue to service quality improvement through the implementation of evidence-based practices. The objective of this study will be to identify why, how, and under what conditions organizational KT strategies have been shown to be effective or ineffective in changing the (a) knowledge, (b) attitudes, and (c) clinical behaviors of allied health professionals in traumatology settings. Methods This is a realist review protocol involving four iterative steps: (1) Initial theory formulation, (2) search for Evidence search, (3) knowledge extraction and synthesis, and (4) recommendations. We will search electronic databases such as PubMed, Embase, CINHAL, Cochrane Library, and Conference Proceedings Citation Index - Science. The studies included will be those relating to the use of organizational KT strategies in trauma settings, regardless of study designs, published between January 1990 and October 2020, and presenting objective measures that demonstrate change in allied health professionals’ knowledge, attitudes, and clinical behaviors. Two independent reviewers will select, screen, and extract the data related to all relevant sources in order to refine or refute the context-mechanism-outcome (CMO) configurations developed in the initial theory and identify new CMO configurations. Discussion Using a systematic and rigorous method, this review will help guide decision-makers and researchers in choosing the best organizational strategies to optimize the implementation of evidence-based practices. Systematic review registration PROSPERO CRD42020216105

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Objective Procedure-related rupture is one of the most feared complications in treating patients with cerebral aneurysm. The primary aim of this study was to estimate the effect of aneurysm size on procedure-related rupture. We also estimated its effect on peri-procedural thromboembolic events. Methods This observational study was conducted using routinely-collected health data on patients admitted for subarachnoid hemorrhage and treated with aneurysm coil occlusion in the CHU de Quebec — Enfant-Jesus hospital from January 1st, 2000 until sample size was reached. Patients were identified from the Discharge Abstract Database using the Canadian Classification of Health codes. Assessment of complications was blind to aneurysm size. Logistic regression models were performed to test associations between aneurysm size and procedure-related rupture or peri-procedural thromboembolic events, and between both procedure-related rupture and thromboembolic events and patients' outcomes. Results This study included 532 aneurysms treated with coil occlusion in 505 patients. Procedure-related rupture occurred in 34 patients (6.7%) and thromboembolic events in 53 (10.5%) patients. Aneurysms of 2 to 3 mm inclusively were not more significantly associated with procedure-related rupture or thromboembolic events than those larger than 3 mm (OR 1.02, 95% CI: 0.9–1.16, p = 0.78 and OR 1.06, 95% CI: 0.96–1.17, p = 0.3, respectively). However, procedure-related rupture had a significant effect on patient mortality (OR 3.86, 95% CI: 1.42–10.53, p Conclusions Very small aneurysm size should not preclude aneurysm coil occlusion. Every measure should be taken to prevent procedure-related rupture as it is strongly associated with higher mortality.

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-to-needle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times.

IntroductionThe SILK flow diverter (SFD) is used for the treatment of complex intracranial aneurysms. Small case series have been reported in the literature but few studies with a large number of patients have been published. We present our experience with the SFD for the treatment of intracranial aneurysms in Canada.MethodsCenters across Canada using SFDs were contacted to fill out a case report form for patients treated with an SFD in their center. Individual centers were responsible for approval from their ethics committee. Image analysis was performed by individual operators. The case report forms were collected and the final analysis was performed.ResultsA total of 92 patients were treated with SFDs in eight centers in Canada between January 2009 and August 2013. The aneurysms were located in the posterior circulation in 16 patients and in the anterior circulation in 76 patients. Most aneurysms (75%) were saccular in shape; 22% were fusiform and 3% were blister aneurysms. The size of the aneurysms varied from 2 to 60 mm with the neck varying from 2 to 60 mm. Perioperative morbidity and mortality were 8.7% and 2.2%, respectively. At the last available follow-up, 83.1% of the aneurysms were either completely or near-completely occluded. The rate of complications was higher for fusiform aneurysms (pConclusionsThe SFD appears to be an important tool for the treatment of complex intracranial aneurysms. Treatment outcomes and complication rates remain a problem, but should be considered in the context of available alternative interventions. Ongoing analysis of flow-diverting stents for radiographic and clinical performance is required.

We report a severe adverse event occurring in the course of a cohort study (ISRCTN13784335) aimed at measuring the efficacy and safety of venous stenting in the treatment of patients with medically refractory idiopathic intracranial hypertension (IIH). The patient was a 41-year-old woman who was not overweight, who presented with severe headache, grade 1 bilateral papilledema and transient tinnitus, refractory to medical treatment. Right transverse sinus stenting was successfully performed. Following surgery, the patient’s state of consciousness decreased acutely with rapid and progressive loss of brainstem reflex. CT scan revealed acute cerebellar and intraventricular hemorrhage with obstructive hydrocephalus. Angioscan revealed normal venous sinus patency and cerebral MRI showed acute mesencephalic ischemia. Mechanical impairment of cerebellar venous drainage by the stent or venous perforation with the large guidewire used in this technique are two logical ways to explain the cerebellar hemorrhage seen in our patient. The risk of such a complication could probably be reduced using alternative tools and technique. However, given the low level of evidence around the safety of transverse sinus stenting in IIH, its formal assessment in clinical trials is required.

Background and Purpose— The purpose of this study was to estimate the performance measures of MR angiography (MRA) in the diagnosis of aneurysm residual flow after coil occlusion. Methods— Patients having at least 1 cerebral aneurysm treated with coil occlusion were prospectively and consecutively enrolled. Time of flight and contrast-enhanced MRA were performed the same day of the DSA follow-up. The degree of aneurysm occlusion and dimensions of the residual flow were evaluated by independent readers at MRA and digital subtraction angiogram. MRA performance measures were estimated in a cross-sectional analysis and repeated in subgroups of aneurysm sizes and locations. MRA predictive values for recurrence were also estimated using a longitudinal design. Results— We obtained 167 aneurysm evaluations for each imaging modality. Class 3 residual flow was seen on digital subtraction angiogram follow-up in 27%. The sensitivity and specificity of MRA was 88% (95% CI, 80–94) and 79% (95% CI, 67–88), respectively. The positive predictive value for a Class 3 recurrence was 67% (95% CI, 51–80) and the negative predictive value was 93% (95% CI, 86–97). Time-of-flight MRA underestimated the length of the residual flow ( P =0.039), whereas contrast-enhanced MRA overestimated its width ( P P =0.01). Conclusions— MRA has sufficient accuracy for screening of aneurysm residual flow after coil occlusion. Due to its lower negative predictive value, recurrent aneurysms should be confirmed with digital subtraction angiogram before planning a retreatment. Routine use of MRA to follow small aneurysms should wait better estimation of its performance in this particular subgroup.

To evaluate the feasibility of performing a functional cerebral venous outflow blockage in two large animals species, the swine and the baboon, for elaboration of venous hypertension models.Cerebral venous outflow pathways were identified on angiogram and venography of three swine and two baboons, and potential approaches to access these structures were assessed. Practicability of performing functional intracranial dural outflow blockage was tested.The main cerebral venous outflow route was the internal jugular vein in baboons and the paraspinal venous network in swine. Both animals had an additional venous outflow structure, the petrosquamous sinus. Access to intracranial venous sinuses was achieved through a percutaneous retrograde approach in baboon but not in swine, due to the absence of a direct connection between the dural structures and the internal jugular vein. A transcranial approach allowed to access dural venous structures in swine. In both models, partial and progressive venous sinus occlusion increased intracranial pressure, while preserving the animal's vital status. At 6 months, all animals are alive with no neurological deficits.Functional venous dural outflow blockage for elaboration of intracranial venous hypertension is feasible in both models. To be effective, the sinus blockage must be performed before the origin of the petrosquamous, an additional venous sinus seen in swine and baboon. The baboon has the greatest advantage of resembling human cerebral venous drainage, which enables an intracranial venous retrograde access. However, the transcranial approach remains a valuable option to access intracranial venous sinuses in swine.

✓The authors report the case of a 12-year-old boy with spinal cord arteriovenous malformation (AVM) and an associated anterior spinal artery (ASA) aneurysm treated with selective coil placement in the context of subarachnoid hemorrhage (SAH). The patient presented with headache. Head computed tomography scanning revealed no abnormal findings. The cerebrospinal fluid was sampled and analyzed and a diagnosis of SAH was established. Investigation, including magnetic resonance imaging of the cord as well as cerebral and spinal angiography, revealed a conus medullaris AVM and a saccular aneurysm located on the ASA at the T-11 level. The aneurysm was thought to be responsible for the bleeding. Superselective ASA angiography showed that the aneurysm was at the bifurcation between a large coronal artery supplying the AVM and the ASA. The relation of the aneurysm's neck to the main spinal axis and the aneurysm's morphological features indicated that the lesion was suited for endosaccular coil therapy. The aneurysm was selectively occluded, using electrodetachable bare platinum coils. Follow-up angiography immediately after surgery and at 6 months thereafter demonstrated complete occlusion of the aneurysm and a perfectly patent anterior spinal axis. On clinical follow-up examination, the patient remained neurologically intact. When the morphological features of a spinal aneurysm and its relation with the anterior spinal axis are favorable, selective endosaccular coil placement can successfully be achieved.

Background: Interprofessional emergency department (ED) models of care, including physiotherapists, have emerged to answer growing demands for ED care. The purpose of this study was to assess the perceptions of ED physicians regarding ED physiotherapy.Methods and findings: Ninety-five ED physicians, members of one of two ED physicians’ associations in the province of Québec, completed a survey (response rate = 14.7%). Most had a positive perception of physiotherapists’ competencies (96.8%) and were confident that ED physiotherapy care is safe and efficient (96.8%).Conclusions: Based on responses from this limited sample, ED physicians have a positive perception of ED physiotherapy models of care.Keywords: Emergency department; Physiotherapy; Advanced practice physiotherapy;Acceptability; Models of care